Health Disparities Research, Caribbean Style

Can minority health disparities still exist even when people of color are the majority population? In the U.S. Virgin Islands (USVI), the answer is yes. Even though the residents of this U.S. territory are predominantly black (Afro-Caribbean) and Hispanic, they still face many of the same health inequities and barriers to care as Americans of color who are minorities on the mainland.

While the USVI–whose three main islands are St. Thomas, St. John and St. Croix–may look like a Caribbean paradise to tourists, many Virgin Islanders live in poverty and have no health insurance. Although the total population of the islands is very small (about 110,000, less than most U.S. cities), it has disproportionately high rates of serious diseases such as AIDS for a community of its size. And even though Virgin Islanders are U.S. citizens, there is remarkably little research data available about health conditions in the USVI–data that is urgently needed in order to develop evidence-based solutions for addressing unequal health outcomes.

What Is an EXPORT Center?If you think an EXPORT center has something to do with international trade–well, not quite. EXPORT stands for (Centers of) Excellence in Partnerships for Community Outreach, Research on Health Disparities and Training. EXPORT centers are funded by the National Center on Minority Health and Health Disparities (NCMHD), one of the National Institutes of Health, through its Project EXPORT program. To date, NCMHD has awarded grants to more than 60 universities, medical centers and research institutions throughout the U.S. and its territories to establish EXPORT centers. The program’s goal is to build research capacity at designated institutions with significant enrollments of students from health disparity populations and to promote participation in biomedical and behavioral research among these populations. For more information about Project EXPORT, visit http://ncmhd.nih.gov.

Now, however, that situation is about to change. The Division of Nursing at the University of the Virgin Islands (UVI) in St. Thomas is taking aim at researching and eliminating health disparities on the islands through its recently established Caribbean EXPORT Center for Research and Education in Health Disparities (CaRE-HD).

In October 2004, the university received a landmark $1.1 million grant from the National Center on Minority Health and Health Disparities (NCMHD), one of the National Institutes of Health, to establish UVI as an EXPORT center. (What exactly is an EXPORT center? See page TK.) UVI nursing faculty members and students are now undertaking research projects, working on community outreach and public health education, and developing the infrastructure for future research efforts aimed at improving health outcomes for populations of color in the USVI.

“Our long-term goal is to have research outcomes related to health disparities that we will disseminate to professional organizations and publish in professional journals for an academic and professional audience,” says UVI Nursing Division chair and associate professor Gloria B. Callwood, PhD, RN, who is the principal investigator for the grant and director of the EXPORT center’s Administrative Core. “We will add to the body of knowledge needed to eliminate these disparities. Through this, we hope to stimulate other research in partnership with other academic institutions.

“We are also forming community partnerships and disseminating health promotion information to have a real-time influence on the behaviors of [local populations] who are at risk, so they can really begin to take a look at their lifestyles,” Callwood continues. “Through these efforts, we can make an impact on reducing the incidence level of morbidity and mortality for our citizens.”

The goals of CaRE-HD will be accomplished through the integrated activities of the center’s four core areas:

• Administrative Core

• Research and Proposed Pilot Studies Core

• Investigator Training and Mentoring Core

• Community Education and Outreach Core.

In the Nick of Time

The university almost missed the opportunity to apply for the NCMHD grant. The faculty had only heard about the grant six weeks before the application was due, says Callwood. Because UVI is the only university on the islands, the nursing faculty did not have the time or resources to suddenly drop everything and write a major grant proposal in such a short time frame. Fortunately, Doris Williams Campbell, PhD, ARNP, FAAN, professor emeritus at the University of South Florida, was a visiting professor at UVI that semester. She has an extensive research background and is well published.

Campbell stepped in and helped the faculty write the grant. “She has the background and experience in grant writing that allowed us to take advantage of this opportunity in a very short time,” Callwood explains.

Campbell, who is African American, is now a co-investigator and consultant for the CaRE-HD project. “What I observed was that there was a real lack of information regarding various health problems in the U.S. Virgin Islands,” she says. Since the nursing program at UVI is the only professional health care program on the islands, she adds, “the nursing faculty needed time, infrastructure and considerable mentoring to increase the capacity to do research and take a good look at the disparities there.”

Unique Challenges

In addition to the scarcity of research data, the U.S. Virgin Islands face other unique health care challenges. The high level of poverty, the lack of structure to ensure people have access to care, and a shortage of health care professionals all contribute to the problem of health disparities on the islands, Campbell says.

“Even though we are American citizens, as a U.S. territory we have impediments,” Callwood explains. “The Medicare cap here is lower than any other place in the nation. We don’t have the same support from the federal government as other jurisdictions or the same access to care. Our health system is limited by our size and geography.”

Because there is a great deal of migration between the different islands in the Caribbean, immigration status is another complicating factor. “We have a high immigrant population, documented and undocumented,” says Callwood. Many of these immigrants come from nations with Spanish-speaking populations.

According to UVI nursing professor Maxine A. Nunez, DrPH, RN, who is the director of CaRE-HD’s Research and Pilot Studies Core, the diseases and health problems that disproportionately impact people of color in the USVI include HIV/AIDS, cardiovascular diseases (heart disease, hypertension and stroke), obesity, cancer, diabetes and infant mortality. If this sounds familiar, it’s because these are the same conditions that have been identified as key health disparity areas for racial and ethnic minority populations on the mainland.

“These issues impact [people of color] across the United States, but they are accentuated on the islands due to the existing disparities here,” says Campbell. “Access to care directly correlates to health outcomes. There is an even greater disparity here because we have a large group of people on the islands who are uninsured and who are in a lower socioeconomic group.”

Building Research Capacity

One of CaRE-HD’s biggest accomplishments to date was presenting a two-day institute, “From Science to Service: A Roadmap for Confronting Health Disparities in the U.S. Virgin Islands.” Held last October in St. Thomas, the event included the dissemination of research, both general and specific to the Virgin Islands, and presentations from scholars from the mainland, including several distinguished minority nursing leaders. The EXPORT center is now in the process of planning a second institute.

Catherine Alicia Georges, EdD, RN, FAAN, a past president of the National Black Nurses Association and current chair of the Department of Nursing at Lehman College in Bronx, N.Y., was the keynote speaker at the first institute. Georges is a native of the Virgin Islands and still has family there. “This grant is critical because it will help define the kind of research to look for positive outcomes,” she says.

While many of the UVI nursing faculty currently have limited research experience, Georges believes they are ideally situated to help eliminate health disparities on the islands. “They have the skills and commitment and are in a great position to make a difference,” she emphasizes. “They are in the trenches, working hard, and they know what the issues are.”

Edith M. Ramsay-Johnson, EdD, RN, professor of nursing at UVI, is the director of the EXPORT center’s Investigator Training and Mentoring Core. She is responsible for developing a research training mentoring initiative for the faculty and students as well as finding participating community partners.

Although she is a long-time nurse and educator, Ramsay-Johnson, a native of the Virgin Islands, says she is a novice when it comes to research, as are the majority of her colleagues. They have all been assigned mentors who are seasoned researchers. Faye A. Gary, EdD, RN, FAAN, a professor at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, Ohio, works with Ramsay-Johnson. “She is guiding me and sharing all sorts of resources to help me grow into the role,” the UVI professor says.

Other mentors and consultants include Phyllis W. Sharps, PhD, RN, FAAN, associate professor and director of the master’s degree program at Johns Hopkins University School of Nursing; Jacquelyn C. Campbell, PhD, RN, FAAN, the Anna D. Wolfe endowed chair at Johns Hopkins School of Nursing; Hossein Yarandi, PhD, Wayne State University College of Nursing; Eugene Tull, DrPH, on leave from the University of Pittsburgh, currently a consultant epidemiologist for the Virgin Islands Department of Health; and Anne Thurland, MS, director of the Diabetes Control Program, Virgin Islands Department of Health.

The cycle of research mentoring is continuing within UVI as the nursing faculty serve in that capacity for their students. Most of the nursing students have completed the “Human Participants Protection Education for Research Teams” online course, sponsored by the National Institutes of Health, Callwood reports. In addition, the students, along with faculty members who weren’t assigned to a specific position within the EXPORT center, have all been trained to work as research assistants.

“We have exposed the students to grant writing and research, and they [now] know how research can drive nursing practice and provide the science [for how care is given],” Callwood says. “I believe if the students see the faculty engaged in this activity [of research], they will see the value in it and take that with them into their own practice. Then they can truly say, ‘there is evidence that what I am doing is based on hard data, and I am not just doing it because I think it will work.’”

Empowering the Community

The nursing students are also required to be involved in a community outreach project to educate and empower the public, local health care professionals and other students. This falls under the auspices of the EXPORT center’s Community Education and Outreach Training Core, which is directed by associate professor of nursing Barbara R. Stright, PhD, RN.

Stright is working on the front lines to promote education and awareness of health disparities to the local population on the islands. Along with a research assistant and her students, she has helped set up community screenings for a variety of health problems—e.g., cholesterol, blood glucose and vision testing–as well as promoting good nutrition and breast self-examination. “We also provide information in English and Spanish on health problems such as high blood pressure, diabetes, breast cancer, prostate cancer, colon and rectal cancer,” she reports.

Partnering with community organizations in this effort is vital, Stright emphasizes. She and her students have taken part in health fairs at churches, schools and for various community service groups. “We talk to the parent, teacher and student associations and to [service organizations] such as the Rotary Club,” says Stright. “Sometimes the projects chose us, in that [a specific group] requested us [to come]; some projects we have chosen. The [health fairs and presentations] all target the needs of the population in the U.S. Virgin Islands and focus on some of the health disparities that are common to the people here.

“Whether we see 15 or 50 people at any given event, we see the need and the interest of the people we interact with,” she continues. “Some people are shy, some don’t know [about certain health issues], and many are well informed but don’t do what they should do [to reduce their risks and improve their health]. The questions the people ask are right on target, whatever the topic might be. I think some of the people I’ve met and talked to have no other source of health care. They may not recognize that they have a problem. They need information and they need attention.”

Stright moved to the Virgin Islands from a small, rural oil community in Pennsylvania. “As a [former] officer in the U.S. Army Nurse Corps, I have lived in many communities in the contiguous states and overseas,” she says. “I noticed that even in the military there was a large underserved population and this has always irritated me. I try to help when I can. I am a white woman who came from a very poor background and I know first hand what it is like to have very little except for your own drive and initiative. I myself have high blood pressure, diabetes, high cholesterol and I’m overweight. I am working on control of all of them, so I know how it feels to struggle with these problems on a daily basis. I think I bring that understanding to the people I meet [at these community events] and they respond.”

Beginning the Research

So far, the Caribbean EXPORT Center has awarded funds to four health disparities research projects, which are awaiting approval by the UVI Institutional Review Board. The projects are:

• A church-based diabetes care survey on St. Thomas. The researcher is Patricia McDonald, PhD, RN, of Case Western Reserve University, who was recently a visiting faculty member at UVI.

• A study of breast cancer risk communication and risk management between patients and providers. The researchers are Ramsay-Johnson and Sandra Millon Underwood, PhD, RN, FAAN, of the University of Wisconsin-Milwaukee School of Nursing.

• A study on the knowledge, attitudes, perceptions and decision-making of pregnant and parenting women of African heritage at risk for or living with HIV/AIDS. The researchers are Stright, Phyllis Sharps and Veronica Njie, MSN, RN, CS, of the Johns Hopkins University School of Nursing.

• A study of health status and access to health care among African American and Afro-Caribbean women in Cleveland, St. Thomas and St. John. The researchers are Ramsay-Johnson and Gary.

A fifth project, which will look at the effects of self management by people with type 2 diabetes in the Virgin Islands, to be conducted by Maxine Nunez, is in the planning stages.

“These by no means represent the entire scope of [the research] we plan to do,” says Nunez. “These happen to be areas of interest to the researchers.”

Once the four studies that have been given tentative approval by the EXPORT Center get started, they will take six months to a year to complete, according to Nunez. The findings will be presented at professional meetings and submitted to journals for publication.

Health disparities research in the U.S. Virgin Islands must be ongoing, adds Nunez, who is a native of the islands. “One question is answered and then another is revealed in the scientific outcomes,” she says. “We have to explore the solutions and do what must be done in order to have an active research base [here]. I don’t think research activities relating to the health disparities in our community are being done. This EXPORT Center is the trigger and support [that will enable us to do this]. It is allowing us to dedicate our time and energy to do the research that is needed.”